What is a Concussion? An In-Depth Q&A with US Lacrosse
Experts

Dr. Margot Putukian and Dr. Ruben Echemendia of the US
Lacrosse Sports Science and Safety Committee were among presenters
at the International Consensus Conference on Concussions in Zurich,
Switzerland.

Concussions are a type of traumatic brain injury (TBI), caused
by a blow or jolt to the head or body that produces shaking of the
brain inside the skull, resulting in mild to severe disruption in
the way the brain normally works. Since there are no clear
biomarkers in the diagnosis of the injury, care providers look for
symptoms — immediate or delayed. Symptoms include headache,
nausea, dizziness, confusion, amnesia, loss of consciousness or
unresponsiveness.

To get a better understanding of concussions, we turned to two
members of the US Lacrosse Sports Science and Safety Committee. Dr.
Margot Putukian and Dr. Ruben Echemendia are world-renowned experts
on concussions and were among the invited presenters at the 2012
International Consensus Conference on Concussions in Zurich,
Switzerland.

What is the biology of a concussion? What actually happens to
the brain?

RE: A concussion creates changes in the
chemistry of the brain that produces a "neuro-metabolic cascade"
that renders cells temporarily inoperative and vulnerable to
further injury. This metabolic cascade is accompanied by a
disruption of the blood supply to the brain, thereby reducing the
amount of glucose (fuel) available to the brain for healing. These
changes affect the entire brain, not just one region.

What are the risks of playing with a concussion? What is
second-impact syndrome?

MP: It is difficult to know the exact risks of
continuing to play while concussed, but in the younger athlete,
there has been a concern that a second insult can occur while the
athlete is still recovering from a first injury, and that a
dysregulation in the blood flow to the brain can then result,
causing a significant increase in the pressure in the brain. Though
considered controversial by some researchers, second-impact
syndrome has been reported in youth athletes and associated with
significant complications, including death.

RE: Continuing to play while having symptoms
places the vulnerable brain at risk for additional injury that may
lead to more severe, prolonged or even life-long problems with
cognitive and psychological functioning. Second-impact syndrome is
rare and thought to occur when an individual sustains a blow to the
brain during a time when the brain has not fully recovered from a
previous concussion. The blow can often be a relatively mild
one.

Are there long-term health implications from concussions?

MP: The majority of concussions resolve in
10-14 days without any known long-term consequences. However, in a
very small percentage, there are persistent symptoms and ongoing
difficulties with cognitive function or balance.

RE: Some studies suggest there can be long-term
changes in neurocognitive functioning; others do not. There is no
consensus among experts in the field. The key appears to be
appropriate evaluation and management of the injury.

What impact, if any, does age play in concussions?

This article appears in the October issue of
Lacrosse Magazine, a special sports science and safety
edition.

Don't get the mag? Join US
Lacrosse and its 400,000-plus members today to start your
subscription.

MP: Younger athletes appear to take longer to
recover and therefore should be treated with caution. Other
modifiers that are associated with a prolonged recovery include an
increased number and duration of symptoms and a history of prior
concussion. Other modifiers that may play a role in prolonged
recovery include a history of migraine headaches, attention deficit
hyperactivity disorder (or other learning disorders) and history of
depression, anxiety or other mental health disorders.

Besides rest (physical and mental), what else can help
recovery?

MP: An initial period of rest is important, and
avoiding cognitive activity, such as texting, video games and
extended computer work, also is important. After a few days, light
exercise can be initiated assuming it doesn't worsen symptoms. It's
unclear if other interventions are helpful in assisting recovery,
but alcohol, aspirin, narcotics and other medications that impair
cognitive function or increase bleeding are typically avoided in
the first few days.

RE: It is very important that athletes with
concussions remain well hydrated, maintain good nutritional habits
and get plenty of sleep. Keep in mind that physical and cognitive
rest does not mean placing the child in a cocoon. Typical
activities of daily living, including school, should be added as
soon as they are tolerated without producing an increase in
symptoms.

What misperceptions about concussions do you encounter?

MP: One myth is that helmets prevent
concussion. Though they are effective in preventing skull fracture
and bleeds, and may lessen impact forces, they do not prevent
concussion. Sometimes the assumption is that putting a helmet on an
athlete will protect them, when it might not. In fact, if they have
a false sense of security, they may play more aggressively and
therefore be at a greater risk for injury. Another myth is that the
greater the impact force, the more likely that a concussion will
occur or the more severe the concussion. There is not enough
research to support this, and what limited data we have actually
suggests that concussive injury can occur with different levels of
impact.

RE: Some people still believe that you need to
lose consciousness or have serious memory impairment to have a
concussion. Neither is true. Some believe that a concussion is a
bruise to the brain; it is not. Many believe that you have to be
hit hard or be hit on the head to have a concussion. Neither is
true.

Can you comment on the effectiveness of neurocognitive
(baseline) testing?

RE: Baseline testing can be very useful in
establishing the pre-injury functioning of the athlete. If
available, athletes should take advantage of baseline testing.
However, baseline testing sometimes creates significant complexity
in the evaluation of an athlete's cognitive functioning. Because of
this complexity, a qualified neuropsychologist should interpret any
neuropsychological testing.

MP: The utility of baseline computerized
neuropsychological testing has recently been questioned. Although
it appears to promising, there are several factors to consider in
NP testing including the effects of fatigue, injury and
motivation.

What are your opinions on the return-to-play laws that have
been passed in 49 states and D.C.?

MP: The Zack Lystedt Law passed in Washington
State was the first of many that have raised the awareness of the
importance of this injury as well as the importance of removing
athletes from play when signs and symptoms of concussion are
present.

RE: These laws are a good first step towards
raising awareness and providing basic guidelines for the management
of concussion. The laws are not uniform across states, and hence
some are better than others.

US Lacrosse contends there yet no scientific evidence to
suggest helmets prevent concussions. Do you adhere to this
position?

RE: Yes, this is accurate. Helmets are designed
to prevent catastrophic head injury, and they are very good at
doing that. They just were not designed to, and do not, prevent
concussion.

MP: We need to explore the effects of various
headgear options and continue to investigate the mechanisms of
injury in lacrosse for both the men's and women's game, and
evaluate interventions that can decrease injury — including
rule changes, rule enforcement, coaches and player education.
Whether future equipment modifications can prevent or lessen the
severity of injury remains unanswered at this time.

Do you have other recommendations from the conference in
Zurich?

MP: There has been a lot of research regarding
the assessment and management of concussion that has led to a more
cautious approach to this important injury. There are advanced
neuroimaging techniques which show promise in demonstrating
functional and structural injury with concussion. There also has
been a significant amount of information regarding the acceleration
forces that occur in different sports that quantify the number,
extent and location of forces to the head with sport.

RE: Thus far we have focused a great deal of
attention, effort and money on baseline testing but have not
focused much on the post-injury evaluation, which is in many ways
far more crucial. It is imperative that any athlete with a
concussion be evaluated by a qualified medical professional who is
specifically trained in the evaluation and management of this
injury. The use of a multidisciplinary team of professionals
— physicians, neuropsychologists and athletic trainers
— is ideal.